Rigid Proctoscope Research Articles

Surgical and postoperative evaluations of rectal adenomas excised with a rigid proctoscope.

Purpose This study presents the surgical and postoperative results achieved with a rigid proctoscope using the transanal endoscopic technique to excise rectal adenomas. The results are compared to the results obtained with other currently employed transanal techniques.Methods We investigated the medical records of patients who underwent transanal endoscopic operations from April 2000 to June 2018 at two tertiary referral centers for colorectal cancer.Results This study included 99 patients. The mean age was 65.3 ± 13.3 years. The average size of the adenomas was 4.6 ± 2.3 cm, and their average distance to the anal border was 5.6 ± 3.3 cm. The average operative time was 65.3 ± 41.7 min. In 48.5% of the operations, the specimen was fragmented, and in 59.6% of the cases, the microscopic margins were free. The rates of postoperative complications and relapse were 5% and 19%, respectively. The mean follow-up was 80 ± 61.5 months.Conclusions The described proctoscope proved to be a viable technique with results similar to other techniques, with the advantage that it allowed greater accessibility for surgeons. Therefore, its use could be implemented and become widespread in surgical practice.

Flexible Video-Endsocopic Injection Sclerotherapy for Second and Third Degree Internal Hemorrhoids

ABSTRACT Background and objectives: Bleeding from hemorrhoids is the commonest cause of rectal bleeding in adults. Injection sclerotherapy of internal hemorrhoids is one of the non-surgical treatments, and is simple, safe and feasible. Conventionally sclerotherapy is performed with rigid proctoscope which has limitations of maneuverability, narrower field of vision and documentation compared to flexible videoendoscope. Therefore, we assessed the efficacy and safety of video-colonoscopic sclerotherapy for bleeding internal hemorrhides. Methods: Seventy-nine patients of bleeding internal hemorrhoids were subjected to colonoscopic sclerotherapy using 1.5% polidocanol in retroflexed or forward viewing positions. Success of treatment was defined as cessation of bleeding for six weeks. Patients were observed for complications and were followed up regularly for 3 months. Results: A total of 79 evaluable patients, 61 had grade II and 18 had grade III hemorrhoids. There was no statistically significant differences in achieving excellent or good results for control of bleeding between patients with grade II and grade III hemorrhoids (100% vs 94,5%; p>0.05). The number of sessions of sclerotherapy required were significantly more in grade II than grade III hemorrhoids (1.1 ± 0.3 vs 1.3 ± 0.7; p = 0.04). No significant complications were noted except for bloating in ten patients (12.6 %) and rectal pain in 6 (7.6%) patients. Median time taken for the procedure was 30 minutes. Conclusions: Video-endoscopic sclerotherapy is safe, well-tolerated and effective treatment for bleeding internal hemorrhoids.(J Dig Endosc 2011;2(1):1-5)

The role of endoscopy in patients with anorectal disorders

The role of endoscopy in patients with anorectal disorders

Anorectal cancer following topical formalin application for haemorrhagic radiation proctitis

Topical formalin has been used as an effective treatment for haemorrhagic radiation proctitis. In the course of reviewing our experience with this modality, we identified two patients who developed anorectal cancer during the follow-up period. From 2001 to 2005, 49 patients who received pelvic radiation for treatment of prostate, rectal or endometrial cancer subsequently developed haemorrhagic radiation proctitis. Four percent formalin was applied in the office setting under direct visualization with a rigid proctoscope and without sedation. Response to treatment was then reviewed. Seventy-eight per cent of patients reported a complete response to formalin application. Only 14% were refractory to formalin treatment. Two patients subsequently presented with anorectal cancer. Topical formalin application in the outpatient setting appears to be an effective first-line treatment for haemorrhagic radiation proctitis. We report the first cases of anorectal cancer which developed subsequent to formalin application. Pelvic irradiation is known to increase the risk of developing a second malignancy, therefore it is impossible to determine what, if any, role formalin application played in the development of the second malignancies.

Elastic band ligation of hemorrhoids: Flexible gastroscope or rigid proctoscope?

To compare rigid proctoscope and flexible endoscope for elastic band ligation of internal hemorrhoids. Patients between 18 and 80 years old, with chronic complaints (blood loss, pain, itching or prolapse) of internal hemorrhoids of grade 1-3, were randomized to elastic band ligation by rigid proctoscope or flexible endoscope (preloaded with 7 bands). Patients were re-treated every 6 wk until the cessation of complaints. Evaluation by three-dimensional anal endosonography was performed. Forty-one patients were included (median age 52.0, range 27-79 years, 20 men). Nineteen patients were treated with a rigid proctoscope and twenty two with a flexible endoscope. Twenty-nine patients had grade 1 hemorrhoids, 9 patients had grade 2 hemorrhoids and 3 patients had grade 3 hemorrhoids. All patients needed a minimum of 1 treatment and a maximum of 3 treatments. A median of 4.0 bands was used in the rigid proctoscope group and a median of 6.0 bands was used in the flexible endoscope group (P < 0.05). Pain after ligation tended to be more frequent in patients treated with the flexible endoscope (first treatment: 3 vs 10 patients, P < 0.05). Three-dimensional endosonography showed no sphincter defects or alterations in submucosal thickness. Both techniques are easy to perform, well tolerated and have a good and fast effect. It is easier to perform more ligations with the flexible endoscope. Additional advantages of the flexible scope are the maneuverability and photographic documentation. However, treatment with the flexible endoscope might be more painful and is more expensive.

Elastic band ligation of hemorrhoids: flexible endoscope versus rigid proctoscope

Elastic band ligation of hemorrhoids: flexible endoscope versus rigid proctoscope

Sucralfate Does Not Ameliorate Acute Radiation Proctitis: Randomised Study and Meta-analysis

During pelvic radiotherapy, many patients develop radiation-induced gastrointestinal symptoms, which may interfere with treatment. Prophylaxis during radiotherapy should ideally prevent acute reaction and the development of delayed injury. Sucralfate, an aluminium sucrose octasulphate, has been used for acute and delayed radiation side-effects. However, conflicting results have been published. We report here a prospective, randomised, placebo-controlled study of prophylactic sucralfate during pelvic radiotherapy. In addition, a meta-analysis of available data from the literature has been carried out. Fifty-one patients with localised pelvic tumours scheduled for curative conformal pelvic radiotherapy (total dose 64-70 Gy over 6.5-7 weeks in 2 Gy daily fractions) were included. Peroral sucralfate 2 g three times daily, or identically appearing placebo tablets, was given during the course of radiotherapy. Symptom registration, endoscopy and biopsies were carried out immediately before radiotherapy, 2 weeks and 6 weeks into the treatment course, and 2 weeks after completing radiotherapy. Mucosal cup forceps biopsies were obtained through a rigid proctoscope. Graded endoscopic appearance and quantitative histology were registered. On the basis of previously published negative reports, an unplanned interim analysis of 44 evaluable patients showed significantly increased diarrhoea in the sucralfate group and the trial was stopped. No difference was seen in other symptoms, endoscopic appearance or histology. A meta-analysis comprising five published studies showed no statistically significant beneficial effect of sucralfate on acute symptoms. Sucralfate cannot be recommended for prophylaxis of acute radiation proctopathy and may even worsen the symptoms.

Predictive Factors of Stenosis after Stapled Colorectal Anastomosis: Prospective Analysis of 179 Consecutive Patients

The incidence, risk factors, and clinical relevance of stenosis of stapled colorectal anastomosis (CRA) were studied prospectively. Anastomotic stricture was defined as the inability of traversing the anastomosis with the rigid proctoscope. The population studied consisted of 179 patients (94 males) with an average age of 59.3 years (range: 20 to 91 years). The main indication for surgery was colorectal cancer in 59% of the cases, followed by diverticular disease in 23%. The first endoscopic control was performed before 4 months in 25% of the patients, between 5 and 10 months in 50%, and during the following 10 months in 25%. Stenosis was verified with the rigid instrument in 21.1% of the cases and with the flexible colonoscope in 4.4%. The barium enema performed in 12 cases confirmed a punctiform stenosis in 5 patients, 4 of whom had been asymptomatic. An endoscopic dilatation was performed on 5 of the 8 symptomatic patients, with one relapse that required an additional dilatation. In the univariate analysis only the lesser 4-month interval was statistically significant (p = 0.033; odds ratio (OR) = 2.3; confidence interval (CI) 95% = 1.06 to 4.97). Male patients (p = 0.057; OR = 2.08; IC 95% = 0.97-4.44) show a tendency to CRA stricture that does not reach statistically significant levels. In the multivariate analysis, only sex (p = 0.04; OR = 4.11; IC 95% = 1.03 to 5.41) and the time interval (p = 0.012; OR = 2.87; IC 95% = 1.25 to 6.57) appear as independent variables in stenosis risk of a stapled CRA. The incidence of this complication depends on the criteria used for defining it. It is clinically relevant in no more than 5% of the patients. Five out of eight patients in category II were treated successfully with an endoscopic dilatation, while the other three improved spontaneously. Early stenosis, although frequent, is generally asymptomatic and disappears spontaneously. Considering the lack of correlation between the degree of stricture and its symptomatology, it is convenient to combine both the anatomic and the clinical criteria in the selection of candidates for an eventual therapeutic procedure.

Hemorrhoidal elastic band ligation with flexible videoendoscopes: a prospective, randomized comparison with the conventional technique that uses rigid proctoscopes

Elastic band ligation by means of a rigid proctoscope is the treatment of choice for patients with symptoms caused by internal hemorrhoids of grade 2 to 3. In contrast to the flexible videoendoscope, the rigid proctoscope has limited maneuverability, has a narrower field of view, and does not allow adequate documentation. Therefore, a randomized trial was conducted to compare the safety and the efficacy of conventional elastic band ligation with videoendoscopic elastic band ligation. A total of 100 consecutive patients (mean age 47 [12] years) with chronically bleeding grade 2 or 3 internal hemorrhoids were randomized to elastic band ligation or videoendoscopic elastic band ligation. For videoendoscopic elastic band ligation, a reusable multiband ligator was attached to the end of a therapeutic upper videoendoscope. From one to 3 bands were placed per session in both groups. Re-treatment was performed every 2 to 3 weeks in both groups until cessation of bleeding and eradication of the hemorrhoids (at least grade 2) were achieved. Thereafter, the patients were followed to assess complications and efficacy. Recurrent bleeding was considered a treatment failure. To achieve the desired therapeutic aims, a significantly lower number of treatment sessions was required in the videoendoscopic elastic band ligation group (1.8 [0.8] vs. 2.4 [0.9]; p < 0.01) and the total number of bands applied was significantly less (2.8 [1.1] vs. 3.7 [1.4]; p < 0.01). Pain was noted after ligation by 25% of patients in the elastic band ligation group compared with 27% of those who had videoendoscopic elastic band ligation. However, analgesic medications were required in only 7% after elastic band ligation and 9% after videoendoscopic elastic band ligation (NS). Post-ligation bleeding that had to be treated endoscopically occurred in 3.5% of the patients of the elastic band ligation group and 3.2% of those in the videoendoscopic elastic band ligation group (NS). Blood transfusion was not required. At a median follow-up of 12 months, there was no recurrence of bleeding in 40 patients (80%) in the conventional elastic band ligation group vs. 43 (86%) in the videoendoscopic elastic band ligation (NS). The long-term efficacy and safety of conventional elastic band ligation and videoendoscopic elastic band ligation are highly comparable. However, when videoendoscopic elastic band ligation is performed, significantly fewer treatment sessions are required.

Treatment of hemorrhagic radiation proctitis with 4 percent formalin.

The purpose of this study was to review our results in patients undergoing treatment with 4 percent formalin for radiation-induced injury to the rectum. A retrospective review of office charts was performed, identifying all patients undergoing formalin treatment. Patient gender, initial malignancy, prior treatments, response to treatment with formalin, complications, and length of follow-up were reviewed. All patients had flexible endoscopy to assess for proximal sources of bleeding. The indication for treatment was a symptomatic patient with endoscopic evidence of radiation injury. A cotton pledget was used for direct application of 4 percent formalin to the affected area via a rigid proctoscope or anoscope. The treatment was repeated if blanching did not occur or if bleeding continued. Patients were followed up at three-week to four-week intervals and treatment was repeated based on the above indications. Treatments were continued until cessation of bleeding occurred or, when treatment failed, operative treatment was required. Thirty-six patients were identified. Three were lost to follow-up. Symptoms included bleeding in all but one patient, who presented with an ulcer. There were 33 (26 male) patients. Seventeen (51.5 percent) patients had prior treatment. The number of formalin treatments ranged from 1 to 13, with a mean of 3.4. The follow-up ranged from 1 to 60 months, with a mean of 18 months. Twenty-nine (88 percent) patients had improvement or cessation of symptoms. Four (12 percent) patients failed treatment. Two patients were noted to have full-thickness ulcers and both failed formalin treatment. No complications were noted related to formalin treatment. We conclude that formalin therapy is a safe and effective form of treatment that can be performed in the office with minimal discomfort and no complications. It can be performed multiple times until results are achieved. Formalin therapy may be useful as a first-line treatment for chronic radiation proctitis, however, a prospective controlled trial comparing modalities is required to prove this to be true.

Closure of Proximal Colorectal Fistulas Using Fibrin Sealant

Fibrin glue has been used in upper gastrointestinal and perianal fistula disease, but its success in proximal colorectal pathology has not been widely documented. This report describes the use of endoscopically injected fibrin glue as a successful adjunct to traditional methods in accelerating the closure of colorectal fistulas. A retrospective review was performed on cases of colon and rectal fistulas treated with fibrin glue using an endoscopic technique of injection. Fistulas were injected via a flexible fiberoptic endoscope with fluoroscopic guidance (three) or directly with a rigid proctoscope (one). Fibrin glue was mixed directly from cryoprecipitate, thrombin, and calcium (one) or using a Tisseel kit (three) (Baxter, Deerfield, IL). Four patients were identified and included: two J-pouch fistulas, a colocutaneous fistula, and a complex rectocutaneous fistula. The median duration of fistula was 33 days (range 4-365 days). Total parenteral nutrition and bowel rest were used in two patients and three required drainage of an abscess. All fistulas were obliterated and patients required a mean of one application of fibrin glue (range one to two). The mean time to resuming a regular diet postinjection was 2 days (range 1-5). No complications were identified. Fistula resolution was documented in all cases with a contrast enema and no patient has had a fistula recurrence at a median follow-up of 12 months (range 6-65). This preliminary series demonstrates that fibrin glue can be used to obliterate proximal rectal, colonic, and pouch fistulas. Endoscopy and fluoroscopy may aid in administering the fibrin glue. This adjunctive technique may shorten the time to fistula closure and may allow some patients to avoid further surgery.

Treatment of colorectal and ileoanal anastomotic sinuses.

This study is designed to describe a technique and report results for treating low anastomotic sinuses. Restorative proctocolectomy and complicated low anterior resections were protected with diverting loop ileostomy. Contrast enemas identified anastomotic problems before ileostomy closure. Pouch-anal or colorectal anastomotic sinuses that failed to resolve with observation were treated before intestinal continuity was restored. With the patient receiving regional or general anesthesia, a rigid proctoscope or anoscope was used to identify the sinus opening. The common wall between the sinus and the bowel lumen was divided under direct vision with laparoscopic cautery scissors, and the sinus cavity was debrided with a suction cautery wand placed through the scope. Six patients with anastomotic sinuses have received outpatient treatment in the described manner during the past two years. Four patients had restorative proctocolectomies for ulcerative colitis, and two had low anastomosis for rectal cancer. Three patients presented with pelvic sepsis before the contrast study; the remainder were asymptomatic. Division of anastomotic sinus was performed one to eight months after diagnosis of the sinus. Following division, anastomotic cavities resolved in five patients by 1 month and in one patient by 12 months. In these six patients, there was one dilatable anastomotic stricture but no other anastomotic complications at follow-up 5 to 16 (mean, 9.2) months after sinus division. When used in conjunction with fecal diversion, sinus unroofing by division of the common wall between the sinus and bowel lumen treats low pelvic sinuses.